05/09/1940
MRN:
991788
Weight:
180lb
Admitting Diagnosis:
Ascites
Admitting Physician:
Wilson James, MD
Latex
Cirrhosis
Paracentesis
| Lab Result | Tested Value | Normal Value Range |
|---|---|---|
| Glucose | 50 | 70-100 |
| BUN | 21 | 5-20 |
| Creatinine | 1.6 | 0.5-1.5 |
| Sodium | 141 | 135-145 |
| Potassium | 3.1 | 3.5-5.0 |
| Chloride | 102 | 95-105 |
| Calcium | 9.9 | 9-11 |
| Lab Result | Tested Value | Normal Value Range |
|---|---|---|
| WBC | 10.1 | 4.8-10.8 |
| RBC | 5.2 | 4.7-6.1 |
| HGB | 12.8 | 12.6-17.4 |
| HCT | 38 | 37-51 |
| MCV | 82 | 80-94 |
| MCH | 29 | 27-31 |
| MCHC | 35 | 33-37 |
| Platelets | 110 | 130-400 |
| Segmented Neutrophils % | 56 | 50-70 |
| Neutrophils, bands | 0 | 0-5 |
| Lymphocytes % | 27 | 20-40 |
| Monocytes % | 6 | 0-15 |
| Eosinophils % | 2 | 0-6 |
| Basophils % | 1 | 0-2 |
| Reticulocytes | 0 | 0-1 |
| Lab Result | Tested Value | Normal Value Range |
|---|---|---|
| PT | 12.4 | 7.6-10.6 |
| PTT | 44 | 26-38 |
| D-Dimer | <0.50 | <0.50 |
| Lab Result | Tested Value | Normal Value Range |
|---|---|---|
| AST | 90 | 5-40 |
| ALT | 99 | 7-56 |
| Ammonia | 60 | 15-45 |
| Bilirubin | 5.2 | 0.1-1.2 |
| Albumin | 2.2 | 3.4-5.4 |
| Time | 2000 | 0000 | 0400 |
|---|---|---|---|
| Heart Rate | 104 | 110 | 108 |
| Blood Pressure | 105/75 | 99/78 | 100/71 |
| Respiratory Rate | 30 | 28 | 29 |
| Pulse Ox | 96% on 2L NC | 98% on 2L NC | 97% on 2L NC |
| Temperature | 98.6 Oral | NOT RECORDED | NOT RECORDED |
| Time | Provider | Notes |
|---|---|---|
| 2000 | Wilson James, MD | 80 yo male presenting to the ED with shortness of breath x a few days. Pt reports increasing fluid accumulation in abdomen over the past week. Petichiae noted to patient BLE and chest. Pt reports several episodes of vomiting blood over the past week and dark tarry stools. Pt with diminished lung sounds bilaterally, abdomen firm and distended. Plan for paracentesis. Pt also with GCS=14, confused to place and time. Asterixis noted. |